Documentos de Académico
Documentos de Profesional
Documentos de Cultura
GPC Menopausia Definitiva
GPC Menopausia Definitiva
1.3. Objetivos 17
1.4. Niveles de evidencia y grados de recomendación 17
i
2. Manifestaciones clínicas 19
2.1. Síntomas y problemas de salud y su relación o no con de la menopausia y la
n
postmenopausia 19
2.2. Síntomas 21
í
2.2.1. Vasomotores
2.2.2. Vaginales
2.2.3. Urinarios
2.2.4. Mamarios
2.2.5. Estado de ánimo
2.2.6. Sexualidad
2.2.7. Esfera cognitiva
2.2.8. Músculo-esqueléticos
2.3. Problemas de salud 24
2.3.1. Osteoporosis y riesgo de fractura
2.3.2. Enfermedades cardiovasculares
3. Síntomas vasomotores y genitourinarios 28
3.1. Síntomas vasomotores 28
3.1.1. Estrategias de prevención y modificación de estilos de vida
3.1.1.1. Obesidad
3.1.1.2. Tabaco
3.1.1.3. Ejercicio físico
3.1.1.4. Otros factores
3.1.2. Intervenciones farmacológicas
3.1.2.1. Tratamiento hormonal
3.1.2.2. Tratamientos no hormonales
3.1.3. Tratamientos alternativos
3.1.3.1. Fitoestrógenos
3.1.3.2. Vitamina E
3.1.3.3. Medicamentos homeopáticos
3.1.3.4. Hierbas medicinales
3.1.4. Otras técnicas
3.1.4.1. Relajación
3.1.4.2. Acupuntura
3.1.4.3. Reflexoterapia
3.1.4.4. Magnetoterapia
3.2. Síntomas vaginales 40
3.2.1. Estrategias de prevención y modificación de estilos de vida
3.2.2. Intervenciones farmacológicas
3.2.2.1. Tratamiento hormonal
3.2.2.2. Moduladores selectivos de los receptores estrogénicos (SERM)
3.2.3. Cremas hidratantes, geles o lubricantes
3.2.4. Tratamientos alternativos
3.3. Síntomas urinarios 43
3.3.1. Tratamiento hormonal con estrógeno con o sin progestágenos
4. Osteoporosis y riesgo de fractura 45
4.1. Factores de riesgo de densidad mineral ósea baja, fractura y caídas 45
4.1.1. Factores de riesgo de densidad mineral ósea baja y fractura
4.1.2. Factores de riesgo de caída
4.2. Evaluación del riesgo de fractura 48
4.2.1. Escalas para evaluar el riesgo de densidad mineral ósea baja
e 4.2.2. Escalas para evaluar el riesgo de fractura
4.2.3. Escalas para evaluar el riesgo de caída
c
4.3. Pruebas para la detección de los cambios de la masa ósea y la tasa de recambio óseo 50
4.3.1. Radiografía convencional
i
Síntomas vasomotores
Síntomas vaginales
Abel Coutado Méndez
Jordi Cassadó Garriga Médico de Familia
Ginecólogo Centro de Salud A Capela
Hospital Mútua de Terrassa El Ferrol, La Coruña
Terrassa, Barcelona
Nicolás Mendoza Ladrón de Guevara
Blanca Gutiérrez Teira Ginecólogo
Médico de Familia Hospital Universitario Virgen de las Nieves
C.S. Pedro Lain Entralgo Granada
Alcorcon, Madrid
Osteoporosis
•5•
Montserrat Tort Donada Maria Betina Nishishinya Aquino
Médico de Familia Reumatóloga y Maestría en Salud
Centro Cochrane Iberoamericano Pública
Barcelona Centro Cochrane Iberoamericano
Barcelona
Búsqueda, revisión y lectura crítica de la literatura
Secretaría
• Fuentes de financiación: Esta guía de práctica clínica ha contado con la financiación externa de Novartis. Los patrocinadores
no han influido en ninguna etapa de su elaboración.
• Conflictos de interés: Los miembros del grupo de trabajo han declarado sus potenciales conflictos de interés y éstos están
disponibles en el formato electrónico de la guía.
•6•
REVISORES EXTERNOS QUE HAN PROPORCIONADO COMENTARIOS ADICIONALES
Agradecemos el esfuerzo llevado a cabo por todos los revisores y en especial a Arritxu Etxebarría por sus aportaciones en la
revisión de los tratamientos y sobre aspectos metodológicos, a M Àngels Pellicer, por la elaboración del anexo 5 (vademécum
y tratamientos alternativos) y a Carlos Isasi, en el tema de osteoporosis y riesgo de fractura.
•7•
s
e
n GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
MANIFESTACIONES CLÍNICAS
o
Síntomas
i
c
Problemas de salud
c
SÍNTOMAS VASOMOTORES
Abreviaturas:
A B C D Grado de recomendación
a Recomendación por consenso del grupo de trabajo
TH Tratamiento hormonal DMO Densidad mineral ósea
DXA Densitometría por absorciometría de rayos X de energía doble DE Desviación estándar
•8•
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
Síntomas vasomotores
Tratamiento Hormonal
Progestágenos
Tibolona
Tratamientos no hormonales
Tratamientos alternativos
•9•
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
Síntomas vasomotores
Hierbas medicinales
Otras técnicas
SÍNTOMAS VAGINALES
Tratamiento Hormonal
Tibolona
• 10 •
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
SÍNTOMAS URINARIOS
Tratamiento Hormonal
OSTEOPOROSIS
• 11 •
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
Osteoporosis
Radiografía convencional
Densitometría
Marcadores óseos
Tratamiento
• 12 •
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
Osteoporosis
Intervenciones farmacológicas
Calcio y vitamina D
Flúor
Tratamiento hormonal
Tibolona
Raloxifeno
Bifosfonatos
Calcitonina
Teriparatide
Tratamientos alternativos
Fitoestrógenos
• 14 •
GUÍA DE REFERENCIA RÁPIDA DE MENOPAUSIA Y POSTMENOPAUSIA
Osteoporosis
Cribado
Tibolona
• 15 •
1. Introducción
1.1. ANTECEDENTES
1.3. OBJETIVOS
• INTRODUCCIÓN 17 •
Los aspectos fundamentales que se abordan en esta GPC son:
Las preguntas a las cuáles quiere dar respuesta esta guía están
especificadas al inicio del capítulo correspondiente.
• 18 INTRODUCCIÓN •
2. Manifestaciones clínicas
1 año
Climaterio más tarde
Transición menopáusica
Perimenopausia
Postmenopausia
2.2.1. Vasomotores
2.2.2. Vaginales
2.2.3. Urinarios
2.2.4. Mamarios
• 22 MANIFESTACIONES CLÍNICAS •
alteraciones previas del estado de ánimo se han mostrado más
determinantes52,53.
2.2.6. Sexualidad
2.2.8. Músculo-esqueléticos
• MANIFESTACIONES CLÍNICAS 23 •
Los síntomas vasomotores y vaginales muestran una asociación
A
causal con la disminución de estrógenos en la menopausia.
2. 3. PROBLEMAS DE SALUD
• 24 MANIFESTACIONES CLÍNICAS •
este ritmo acelerado de pérdida puede ser más prolongado en
el tiempo71,72.
• MANIFESTACIONES CLÍNICAS 25 •
2.3.2. Enfermedades cardiovasculares
•MANIFESTACIONES CLÍNICAS 27 •
3. Síntomas vasomotores y genitourinarios
3.1.1.1. Obesidad
3.1.1.2. Tabaco
Una revisión sistemática (RS) Cochrane que incluye 21 ECA y 2511 Estudios de
tratamiento
mujeres103 mostró que el TH administrado por vía oral durante un
(1a)
periodo de entre 3 meses y 3 años, comparado con placebo,
reduce la frecuencia semanal de los sofocos. La magnitud del
efecto está relacionada con la intensidad de los síntomas y la
duración del tratamiento. La disminución de los síntomas
vasomotores es superior para los estrógenos combinados con
progestágenos (OR: 0,18; IC del 95%: 0,13-0,24), que para los Estudios de
estrógenos solos (OR: 0,37; IC del 95%: 0,26-0,54])103. ECA posteriores tratamiento
confirman que tanto los estrógenos104-107 como diferentes formas (1b)
de estrógenos combinados con progestágenos son superiores al
placebo108-110.
Diversos ECA controlados con placebo han mostrado que los Estudios de
progestágenos administrados vía oral o intramuscular, en mujeres tratamiento
peri y postmenopáusicas144-147, con antecedentes de cáncer de (1b)
mama148 o de cáncer endometrial149, reducen significativamente
los síntomas vasomotores. Sin embargo, los progestágenos
administrados en forma de crema han mostrado resultados
contradictorios150,151.
Tibolona
Veralipride
Clonidina
Metildopa
Gabapentina
Antidepresivos
3.1.3.1. Fitoestrógenos
3.1.3.2. Vitamina E
De los cuatro ECA que han comparado la cimicífuga con los Estudios de
estrógenos conjugados216,217,219,220, todos excepto uno que es tratamiento
favorable al tratamiento con cimicífuga 216 , han mostrado (2b)
beneficios similares para ambos tratamientos.
Otros preparados
3.1.4.1. Relajación
3.1.4.2. Acupuntura
3.1.4.3. Reflexoterapia
3.1.4.4. Magnetoterapia
Estrógenos
• Edad • Tabaco
• Raza blanca • Alcohol
• Bajo peso o pérdida de peso • Cafeína
• No utilización actual de tratamiento • Baja ingesta de calcio y vitamina D
con estrógenos • Fármacos (anticonvulsivantes,
• Historia previa personal o familiar de heparina, litio, etc.)
fractura
• Antecedentes de caídas
• Baja puntuación en uno o más de las
medidas de actividad o función física
< 65 años 0
65-69 1
70-74 2
75-79 3
80-84 4
mayor de 85 5
Sí 1
No 0
Sí 1
No 0
¿Pesa 57 Kg o menos?
Sí 1
No 0
¿Fuma actualmente?
Sí 1
No 0
Sí 1
No 0
T-score >1 0
T-score entre -1 y -2 2
T-score entre -2 y -2,5 3
T-score < -2,5 4
Ejercicio físico
Exposición al sol
Tabaco
Cafeína
Fuente: Gillespie WJ, et al. Interventions for preventing falls in elderly people358, * Robertson MC, et
al. Preventing injuries in older people by preventing falls359.
Suplementos de calcio
Según los resultados de esta RS, sólo 5 ECA evaluaron el riesgo Estudios de
de fractura, mostrando una reducción no significativa, tanto para tratamiento
fracturas vertebrales (RR: 0,79; IC del 95%: 0,54-1,09) como no (1a)
vertebrales (RR: 0,86; IC del 95%: 0,43-1,72)364. Las limitaciones de
los estudios fueron la pérdida de pacientes en el seguimiento, la
heterogeneidad de los datos y la falta de uniformidad en la
medición de los resultados.
Estudios de
El calcio en general es bien tolerado y los datos sobre efectos tratamiento
adversos son escasos. Estudios observacionales sugieren que los (2b)
• OSTEOPOROSIS Y RIESGO DE FRACTURA 59 •
suplementos de calcio incrementan el riesgo de cálculos renales
en un 20%314.
Vitamina D y análogos
Las RS disponibles no han demostrado que los ECA que combinan Estudios de
calcio y vitamina D comparado con placebo o dieta normal tratamiento
muestren efectos superiores en el cambio de la DMO que los ECA (1a)
que comparan calcio versus placebo364,366. Asimismo, tampoco
se ha podido confirmar los esperados resultados intermedios sobre
el cambio de DMO al administrar calcio en ambos brazos de los Estudios de
ECA o cuando el calcio sólo se ha dado al grupo control. Estas tratamiento
mismas inconsistencias también ocurren cuando se evalúan (1a)
fracturas365,366.
Tibolona
4.4.3.5. Bifosfonatos
Etidronato
Clodronato
Alendronato
Pamidronato
Tiludronato
Ibandronato
Zoledronato
Risedronato
Calcitonina
Teriparatide (PTH)
Diuréticos tiazídicos
Ranelato de estroncio
Fitoestrógenos
Grupo de edad
Fracturas de cadera 1 2 5 14 39 70
prevenidas
NNC para prevenir una 7446 4338 1856 731 254 143
fractura de cadera
Número
factores 50 años 60 años 70 años 80 años 50 años 60 años 70 años 80 años
riesgo
Muy alto riesgo (Malmo, Suecia) Alto riesgo (Edimburgo, Reino Unido)
5.1.3. Tromboembolismo
5.2. TIBOLONA
(1.1)
(1.2) (1.8)
Son intensos o
Sí afectan a la No
calidad de vida
(1.3) (1.7)
Sí Acepta tratamiento No
hormonal3
(1.6)
1 Medidas no farmacológicas: práctica de ejercicio físico, evitar el sobrepeso, abstención tabáquica, ingesta moderada de alcohol y café y evitar situaciones de calor.
2 Informar sobre posibles riesgos y beneficios.
3 Ver notas prácticas sobre el tratamiento hormonal.
1
o
m 6.1. Mujeres con síntomas vasomotores
(2.1)
(2.2) (2.5)
Importante Grado de Leve
afectación
(2.3) (2.4)
Sí Persisten los síntomas No
(2.1)
Estudio de osteoporosis
secundaria (3.3) No
Sí Fractura previa por
fragilidad
Causa de
Sí (4.1) osteoporosis (4.2) No
secundaria1
Estudio de osteoporosis
secundaria (4.3) (4.4) No
Sí Fractura previa por
fragilidad
Evaluar e intervenir sobre factores de riesgo Evaluar e intervenir sobre factores de riesgo
de caídas modificables1 de caídas modificables1
Sí (4.5) (4.8) No
En una primera etapa las búsquedas fueron restringidas a RS, metanálisis y GPC. Se
seleccionaron los estudios correspondientes a población adulta (mujeres
postmenopáusicas). Las búsquedas se llevaron a cabo en MEDLINE, EMBASE y
Cochrane Library, desde 1990 a diciembre del 2003. Se aplicaron los filtros de
búsqueda de GPC del Centre for Health Evidence de Canadá y el de RS del NHS
Centre for Reviews and Dissemination del Reino Unido. Se rastrearon las direcciones
de GPC en Internet (véase Anexo 9), se realizaron búsquedas en publicaciones
secundarias (Bandolier, ACP Journal Club, Clinical Evidence) y en los buscadores de
Internet TRIP database y SumSearch.
Las RS y las GPC son documentos de síntesis crítica que tienen como objetivo revisar
de forma sistemática y con criterios explícitos la literatura científica, proporcionando
una información objetiva, fiable y precisa, que ayude a fundamentar mejor las
decisiones sanitarias.
• 92 ANEXOS •
Revisiones sistemáticas Cochrane en proceso de elaboración
En Agosto de 2004 NICE publicará una GPC sobre caídas (Falls: the assessment
and prevention of falls in older people) y en junio de 2005 una GPC sobre
osteoporosis (www.nice.org.uk/).
Por su parte, la Canadian Task Force va a publicar próximamente sus
recomendaciones sobre el TH, la osteoporosis y los protectores de cadera
(http://www.ctfphc.org/).
• ANEXOS 93 •
ANEXO 2.
• 94 ANEXOS •
Estudios de historia natural y pronóstico
2c Estudios ecológicos.
RS = Revisión sistemática
• ANEXOS 95 •
Diagnóstico
Grado de Nivel de evidencia Fuente
recomendación
Climaterio: periodo de la vida de la mujer que se extiende desde 2-8 años antes de
la fecha de la menopausia hasta 2-6 años después de la última menstruación.
Premenopausia: etapa de 2-6 años previa a la menopausia, que puede cursar con
sintomatología.
• 98 ANEXOS •
ANEXO 4.
Las fuentes naturales más ricas en calcio son la leche, el yogur y los quesos curados.
Otras fuentes de calcio son el pan, las sardinas, y la leche de soja fortificada con calcio
(la mantequilla, la nata y los quesos blandos son fuentes pobres de calcio). En la
siguiente tabla se ofrece información detallada del contenido de calcio en los alimentos:
Leche y lácteos
Leche (todo tipo) 200 ml (vaso) 240
Helado 60 g 60
Quesos y yogur
Yogur natural 125 g (unidad) 250
Yogur de frutas 125 g (unidad) 170
Queso curado 30 g 225
Queso blando (Brie) 30 g 80
Pasta con queso 200 g 340
Pizza con tomate y queso 170g 450
Dulces
Chocolate blanco 50 g (tableta) 140
Barra de chocolate con leche 50 g (tableta) 110
Pan y cereales
Pan blanco (rebanadas) 4 x 30 g (rebanadas) 200
Pan integral 4 x 30 g (rebanadas) 120
Cereales enriquecidos con calcio 30 g (vaso) 140
Pescado
Sardinas en aceite 60 g 300
Salmón 60 g 50
Vegetales
Tofu 60 g 300
Espinacas cocidas 90 g 130
Judías cocidas 150 g 80
Nueces y semillas
Almendras 30 g 70
Tahini (pasta de sésamo) 30 g 200
• 200 ml de leche
• 1 unidad de yogur
• 30 g de queso duro
• 200 g de pasta con queso
• 200 ml de leche de soja enriquecida con calcio
• 60 g de sardinas
• 4 rebanadas de pan blanco
• 1 vaso de leche enriquecida con calcio y cereales
• 100 ANEXOS •
ANEXO 5.
• ANEXOS 101 •
TRATAMIENTO HORMONAL
ESTRÓGENOS
Oral
Transdérmico y percutáneo
Vaginal
• 102 ANEXOS •
PROGESTÁGENOS (para utilizar conjuntamente con estrógenos)
Oral
Estradiol, valerato
2 mg/día x 21 días 11 grageas estradiol
Medroxiprogesterona, Perifem ® 10 grageas combinadas
acetato 10 mg (días 12 a 21 del ciclo)
Otros
• ANEXOS 103 •
TIBOLONA
OTROS
HIDRATANTES VAGINALES
• 104 ANEXOS •
SUPLEMENTOS ORALES DE VITAMINA D
Dosis diaria recomendada: 400-800 UI
Calcio
Sal de calcio elemento Colecalciferol Presentación Nombre comercial
Calcio, carbonato 1,25 g 500 mg 400 UI Comp.* masticables Ideos, Mastical D ®, Ostine ®
Carbocal D, Cimascal D ®,
1,5 g 600 mg 400 UI Comp. masticables
Disnal, Veriscal D ®
CALCITONINA
Calcitonina ®
Calcitonina de salmón 200 UI/24h (varios laboratorios), 200 UI/nebulización
(Salcatonina) Calsynar ®, Miacalcic ®,
Oseototal ®, Ospor ®,
Osteobion ®
• ANEXOS 105 •
CALCITONINA (continuación)
60mg/24h Evista ®
Raloxifeno 60 mg comp.*
Optruma ®
BIFOSFONATOS
* Comp.: comprimido
¤ No financiado por el Sistema Nacional de Salud
• 106 ANEXOS •
ANEXO 6.
La dificultad de presentar un material didáctico que pueda ser útil para todo el
espectro de mujeres ha llevado a preparar una relación de puntos clave adicionales
que pueden ser de ayuda al realizar las entrevistas con las mujeres. Cada profesional
puede adaptar esta información en función de las circunstancias específicas de
cada mujer, de su nivel cultural, deseo de ser informada con detalle, etc. Al final de
la sección se proporciona un modelo de documento de información básica sobre
la menopausia y direcciones de interés.
¿Qué es la menopausia?
• ANEXOS 107 •
¿Cuáles son los síntomas de la menopausia?
¿En qué consiste el tratamiento hormonal (TH) para los síntomas de la menopausia?
Los riesgos del TH han llevado a la Agencia Española del Medicamento, encargada
de vigilar la seguridad de los medicamentos, a recomendar el TH durante el mínimo
tiempo posible y a la mínima dosis necesaria en aquellas mujeres en las que los
síntomas sean muy molestos y alteran su calidad de vida.
• 108 ANEXOS •
La ingesta de bebidas frías, el evitar las comidas picantes, el café y alcohol pueden
aliviar en ocasiones los sofocos. Asimismo, también puede resultar útil ventilar las
habitaciones, cambiarse de habitación, tomar una ducha templada o fría o usar
aire acondicionado. La práctica del ejercicio, el dejar de fumar y la pérdida de
peso, son medidas que pueden ser beneficiosas.
¿Son de utilidad los remedios alternativos o "naturales” para tratar los sofocos o la
sequedad vagina?
Las mujeres tienen más probabilidad de desarrollar osteoporosis que los hombres y
sobretodo si presentan antecedentes personales o familiares de fractura. Determinados
factores pueden también favorecer la aparición de osteoporosis: el tabaco, el
consumo excesivo de alcohol, tomar una dieta pobre en calcio, ser muy delgada
y no realizar ejercicio físico.
Hacer una dieta rica en calcio y vitamina D, practicar ejercicio físico de manera regular,
no fumar y tomar el sol de manera moderada son medidas importantes en toda mujer
con osteoporosis.
Las principales medidas que se pueden llevar a cabo son sencillas y no comportan
riesgos asociados. Las más beneficiosas son dejar de fumar, practicar regularmente
ejercicio físico, seguir una dieta sana y equilibrada, controlar el peso, moderar la
ingesta de alcohol y café y seguir una dieta rica en calcio.
• 110 ANEXOS •
RECURSOS E INFORMACIÓN SOBRE LA MENOPAUSIA
En español:
En inglés:
• ANEXOS 111 •
ANEXO 7.
Síntomas vasomotores
Riesgos y beneficios
• 112 ANEXOS •
ANEXO 8.
Factores facilitadores
Barreras potenciales
• ANEXOS 113 •
ANEXO 9.
Directorios en castellano
Fisterra
http://www.fisterra.com/recursos_web/castellano/c_guias_clinicas.htm
Página de Rafa Bravo
http://infodoctor.org/rafabravo/guidelines.htm
Medicina de familia.net
http://www.medicinadefamilia.net/guias/guias.asp
Bases de datos
National Guideline Clearinghouse.
http://www.guidelines.gov/
Guidelines Finder
http://rms.nelh.nhs.uk/guidelinesfinder/
Canadian Medical Association. CMA Infobase
http://mdm.ca/cpgsnew/cpgs/index.asp
Health Services/Technology Assessment Text
http://text.nlm.nih.gov/
Buscadores
SUMSearch
http://sumsearch.uthscsa.edu/espanol.htm
TRIPdatabase
http://www.update-software.com/scripts/clibNG/HTML/TRIPUsernameLogon.htm
• 114 ANEXOS •
Revisiones sistemáticas
Pubmed
http://www.ncbi.nlm.nih.gov/PubMed
Revistas médicas a texto completo
http://freemedicaljournals.com/
ACP Journal Club
http://www.acponline.org/journals/acpjc/jcmenu.htm
Bandolier
http://www.jr2.ox.ac.uk:80/Bandolier
Bandolera (versión en castellano de Bandolier)
http://infodoctor.org/bandolera
Clinical Evidence
http://www.evidence.org/
CASP - Critical Appraisal Skills Programme
http://www.public-health.org.uk/casp/
CASPe. Programa de habilidades en lectura crítica – España
http://www.hrc.es/CASPe.html
• ANEXOS 115 •
ANEXO 10.
ACRÓNIMOS
TH: Tratamiento Hormonal (incluye tanto estrógenos como estrógenos con o sin
progestágenos y a la tibolona)
US: Ultrasonidos
• ANEXOS 116 •
Bibliografía
• BIBLIOGRAFÍA 117 •
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32. Coope J. Hormonal and non-hormonal interventions for menopausal symptoms. Maturitas
1996; 23: 159-168.
33. Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based
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